Improving preparedness for Ebola, epidemic-prone diseases

The arrival of Ebola in Lagos on July 20, 2014 created serious concerns to the global health community.

The recent Ebola outbreak in the Democratic Republic of Congo (DRC), which has spread to Uganda and is threatening to escalate to more African countries, has put health authorities on red alert. The declaration of the Ebola outbreak as a Public Health Emergency of International Concern (PHEIC) last week by the World Health Organisation (WHO) has called for more work on the part of regulatory agencies.

According to the National Action Plan for Health Security (NAPHS) Federal (2018-2022), over the past two years, Nigeria has been confronted with several outbreaks of epidemic-prone diseases, including measles, yellow fever, cerebrospinal meningitis, cholera, Lassa fever, and monkeypox.

In response to some of these disease outbreaks, public health workers have conducted vaccination campaigns, while also providing infection prevention and control training to health workers, established new laboratory testing capacity, and conducted communication and engagement activities to communities.

The Nigeria Centre for Disease Control (NCDC), which serves as the National Focal Point for the International Health Regulations 2005 (NFP IHR), is responsible for surveillance and response to these outbreaks, and works closely with the National Primary Healthcare Development Agency (NPHCDA) when a vaccination response is needed.

Unfortunately, the number of zoonotic and epidemic-prone disease outbreaks is unlikely to subside. A recent modeling study of risk for viral haemorrhagic fevers identified Local Governments (LGAs) in Nigeria have a high risk for having an index case for Ebola virus disease, Crimean-Congo haemorrhagic fever, and Lassa fever.

Furthermore, models of epidemic and pandemic potential based on local and international connectivity showed that LGAs in Nigeria are some of the highest potential in Africa for the global spread of viral haemorrhagic fevers.

A recent strategic risk assessment conducted by Nigeria and facilitated by the WHO identified the risk of meningitis, cholera, yellow fever, Lassa fever, and terrorism as both “almost certain” in likelihood with a critical impact.

An assessment of Nigeria’s capacity to prevent, detect, and respond to these public health threats, called the Joint External Evaluation (JEE), was conducted in June 2017, in addition to recommendations from the 2010 Performance of Veterinary Services (PVS) assessment. The JEE identified that Nigeria has substantial room to develop its health security capacities.

Dr. Chikwe Ihekweazu is the Director General (DG)/Chief Executive Officer (CEO) of the NCDC. The consultant epidemiologist told The Guardian what the centre is doing to improve emergency preparedness and response in Nigeria.

Nigeria just marked the anniversary of the first Ebola case in Lagos on July 20, 2014. Are we prepared for another Ebola outbreak? If yes, how? If no, why?
Compared to July 2014, we are much better prepared for an Ebola outbreak. You know about outbreak preparedness, you don’t actually prepare for an Ebola outbreak. You prepare for those outbreaks that happen commonly and through the response to common incidents you prepare for the unusual. Since 2014, we have focused on building the new national public health institute in Nigeria called the NCDC and through this organisation we have built our capabilities across the various aspects of preparedness. So when you talk about preparedness, you talk about three broad areas of engagement- first, the prevention, detection and response.

Across a range of epidemic prone diseases that are common, we continue to educate Nigerians on the risks and then what they need to do to mitigate that risk and prevent themselves from getting infected. That is different from some diseases you have to be vaccinated, for other you improve water and sanitation like cholera. For others that don’t happen in Nigeria like Ebola you try to improve the point of entry screening you see at the airport with the thermal cameras. Now when prevention fails the next step is detection. Detection depends primarily on two things. Doctors or clinicians or any healthcare worker being able to suspect an unusual disease in an individual and secondly having the laboratory capacity to confirm that disease is whatever it is.

In July 2014, we didn’t have a National Reference Laboratory (NRL) in Nigeria, We had a few laboratories in specific universities that have developed their capacities like the ones at Redeemer’s University and the Lagos University Teaching Hospital (LUTH) but we didn’t have NRL. But now we have a full-fledged NRL at Jabi in Abuja which is capable of doing the diagnoses of most causes of epidemic diseases both bacterial and viral causes. So our capability of making that diagnoses in Nigeria has increased exponentially. We have a mobile laboratory that we can deploy to any part of the country if needed. The final part is about the response. In the July outbreak in 2014 we had to rely on two groups of people. Firstly are graduates of the Nigeria Field Epidemiology Training Programme (NFETP) and secondly our people that happen to be working on the polio response at the time through the Polio Emergency Operation Centre (EOC) who were then repurposed for Ebola. Now we have built on all of those and we have teams in NCDC that are used to responding. We have a new EOC and we are supporting every state in Nigeria to develop one. We have done that in 16 states. We have people that are now used to responding all the time. To tie all of these together is a communication and digital surveillance platform that we call Surveillance and Outbreak Response Management System (SORMAS). So there is information is sent online across the country on a daily basis. Across the three spheres of prevention, detection and response we are a lot more prepared and this you can demonstrate from our response for all the commonly occurring outbreaks in Nigeria.

How far with isolation infrastructure since makeshift ones like the Infectious Disease Hospital (IDH) in Yaba, Lagos was used in 2014?
This is a longer-term plan but right now we are working with hospitals across the country to improve facilities to manage infectious diseases. Our plan is to have a treatment and isolation facility in every state capital. There are some locations where we already have fairly complex infrastructure in Abakiliki (Ebonyi state), in Owo (Ondo state) and Irrua (Edo state).

This is related to their management of cases of Lassa fever. Now there are two critical locations we are focusing on that are in Lagos and Abuja where we want to build state-of-the-art centres. We started the construction of one in University of Abuja Teaching Hospital in Gwagalada. We just completed the foundation phase. It will be a state-of-the-art treatment centre in Nigeria while we continue to support states to put on centres. I hope in the next few months to invite you to the opening of this state-of-the-art treatment and isolation centre at the heart of the nation’s capital.

How about the Infectious Disease Hospital (IDH) in Yaba that was used in 2014 Ebola outbreak?
At least it is a lot better than it used to be. Lagos has a challenge of many things, the density of the population, the facilities and all of that. So we have worked with the Lagos state government with support of the Canadian government to set up a state-of-the-art laboratory. What we have not done is to fully identify what exactly needs to happen in IDH whether to break down that building and rebuild or to renovate. NCDC has a longer plan of identifying a location for a centre just like the one we are doing in Abuja.

How about the one in LUTH?
There are centres in LUTH but none of them are at the level we want them to be. So they have isolation centre in LUTH but they are not at the standard where we would like them to be.

There was a report published last year by a group with website- PreventEpidemics.org where Nigeria was rated 39 per cent out of 100 per cent scores in terms of preparedness for epidemics. In fact, the United States (US) group said Nigeria is not ready?
We carried out in 2017 a Joint External Evaluation of International Health Regulations Core Capacities of the Federal Republic of Nigeria. This is an evaluation where you bring in your peers from different countries to go through with you around all your areas preparedness and there are 19 areas from legislation to coordination, Antimicrobial Resistance (AMR), zoonotic diseases, surveillance among others. Out of all of that our average score was 39 per cent. The good thing is that this happened nearly two and half years ago now. Since then we have been improving on our scores. So this is basically what our baseline was two and half years ago. If we were to redo this evaluation again we will be a lot better placed. By the end of this year we are going to do a mid term evaluation of this. But I think this is actually a demonstration of our openness in terms of our willingness to better understand what are deficits are and then identify those specific areas that require improvements. So if you look at things like our laboratory systems where we scored fairly low at the time, if we were to do this today we will come out with much better scores.

How much does Nigeria spend yearly on epidemic emergencies, say in 2018?
In 2018, the NCDC budgeted approximately N1.5 billion on epidemic preparedness and response activities. In addition to this, development partners provided, in addition, support worth approximately N10 billion. These activities included simulation exercises, rapid response team deployments, establishment and operations of EOCs at sub-national level, training and capacity building at national and sub-national level, roll-out of SORMAS for digital surveillance and other related activities.

How far with the National Action Plan for Health Security (NAPHS)? The estimated cost of Nigeria’s NAPHS is N134 billion over five years – that is N27 billion per year. This is about 0.3 per cent of the 2018 federal budget.
Last year we sat down with several other agencies and partners across the country and came together, after the evaluation, and put together a five year NAPHS. So this is bringing together all the activities we want to carry out, costing all of them, not only the ones NCDC wants to carry out but across all the other agencies, parastatals, the military, agriculture, environment and then gave ourselves responsibilities and then every agency will now go back and source the funding to carry out its own area. This is really recognizing that health security is not any ministry or parastatals sole responsibility. It is really multi agency responsibility and this plan helped us bring all the actors together. In bringing all the actors together we actually achieved one thing that has never happen before. People hardly work together. In developing the plan we had to work with several partners that we had not work with previously. So it created a community around health security that we did not have previously.

Certainly you must have gaps?
We have many gaps. In every area we have gaps. The work we do if is very complex. A lot of the requirements either from the laboratory side the reagents many of them are not available here. The training costs are enormous. The gaps in the animal side are even worse; you can go any abattoir in Nigeria and see how the conditions are. There are huge gaps but I think now we have a plan, we have a framework to address these gaps. The cost of the plan is established and we all know what we need to do in terms of preparedness across the country.

How far with the Regional Disease Surveillance Systems Enhancement (REDISSE), which was established in response to the 2014-2015 West African Ebola crisis by the World Bank established to cover all countries in the ECOWAS sub-region, including Nigeria?
REDISSE is an initiative of the West Africa Health Organisation (WAHO) through the regional centre for disease control. So the idea came out of the Ebola outbreak in West Africa where we realized that we are not really prepared across the region. But in addition, we are not only prepared for each country; we were not prepared as a region. So the World Bank came up with this funding facility across West Africa. It is not unique to Nigeria, it is just that we are a big country and we got a fair chunk of it. Well every country is supported to increase its preparedness. It is a five-year funding opportunity. For us it’s a credit, for other countries it is a grant, the countries that are poorer than us. For us it is a soft credit at very low interest rate payable back over 30 years. But it is a credit, to me there is a responsibility on us to make sure that the funds are well used and well executed. With this we have a project implementation unit here at NCDC where we are quietly working across different areas to improve priority areas. Some of our EOCs improvement work is funded with that. Also the digitalization of surveillance is funded through that. So very specific projects that will improve our preparedness are funded through this credit.

How much is it worth?
It is worth $90 million over five years. It is payable over 30 to 35 years with one per cent interest rate.

I heard that the NCDC is captured in the emergency preparedness fund and the provisions in the Basic Health Care Provision Fund (BHCPF). How far with that?
So we have a very small part of the emergency fund. It is 50 per cent of the five per cent of the one per cent of the consolidated revenue fund (CRF). One per cent of the CRF goes to the fund; five per cent is for emergency response. Out of that half of it comes here; half of it will go to ambulance services. As at now the problem we have is that whenever there is an outbreak there wasn’t any pool of funds with which would can rapidly respond.

So every time there is an outbreak we had to start looking for money, begging partners or writing to the ministry and sometimes there were not sufficient reagents. So this would enable us improve our preparedness. It would also have some direct patient benefits. One of the things we want to do is an indigent fund for managing Lassa fever patients. At the moment when we are working at the Lassa fever outbreak, in every teaching hospital people still have to pay for care, even though the core commodities like Rivaparin has always been free, the hospital care itself is still paid for and this is a disincentive for people to come into hospital. So we are setting up this fund so that anybody that has Lassa will be treated in those hospitals for free. So these are some of the initiatives to improve preparedness and response across the country.